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N U R SE ED U C A T I O N

Nurses perception of disaster: implications for disaster nursing


curriculum
Fung WM Olivia, Lai KY Claudia and Loke Alice Yuen

Aims and objectives. The aims of the study were to identify nurses perception of disaster, whether they considered some of the
events that have occurred in Hong Kong to be disasters and the types of disastrous events that they considered likely in Hong
Kong.
Background. The frequent occurrence of disasters has caused concern internationally. When disaster strikes, the demands on
nursing staff are much higher than those on other healthcare professionals. There is little understanding of the concept of
disaster among nurses in Hong Kong.
Design. This was a descriptive study. A questionnaire was used to explore nurses perception of disaster.
Method. The questionnaire was distributed to all registered nurses studying in a masters degree programme in a university in
Hong Kong.
Findings. Only 123 out of the 164 respondents (75%) gave a description of disaster in the open-ended question. Sixty-one per
cent of them described unfortunate events with large numbers of victims as disasters. The Lan Kwai Fong tragedy stampede
caused by over-crowdedness (909%) and the severe acute respiratory syndrome outbreak (896%) were commonly referred to
as disasters in Hong Kong. Fires in tall buildings (616%), infectious disease outbreaks (61%) and stampedes caused by
overcrowding (488%) were rated as the events most likely to happen in Hong Kong.
Conclusion. Understanding how nurses perceive disaster and the likelihood of disastrous events is the initial step for disaster
planning and the development of a disaster nursing curriculum in Hong Kong.
Relevance to clinical practice. All nurses around the world should be equipped with knowledge and skills for disaster care. This
study provides information and implications for related research and the development of a disaster nursing curriculum to meet
the global demand for disaster preparedness.
Key words: disaster planning, Hong Kong, nurses, nursing education, perception, preparation
Accepted for publication: 2 November 2008

Background
An average of one disaster per week occurs somewhere in the
world (Veenema 2003). The frequent occurrence of disasters
has raised international concern among various professionals,
such as those in civil and computer engineering, telecommuAuthors: Fung WM Olivia, MPH, BN, RN, Clinical Associate,
School of Nursing, The Hong Kong Polytechnic University, Hong
Kong; Lai KY Claudia, PhD, MN, BHS, RN, Associate Professor,
School of Nursing, The Hong Kong Polytechnic University, Hong
Kong; Loke Alice Yuen, PhD, MN, BSN, RN, Professor, School of
Nursing, The Hong Kong Polytechnic University, Hong Kong

nications, building and surveying, city emergency response


system, fire department and police force, not to mention the
healthcare disciplines (Burkle 1999). The World Conference
on Disaster Management organised by the Canadian Centre
for Emergency Preparedness (2008) in the past 18 years have
attracted over 1800 participants from numerous different
Correspondence: Loke Alice Yuen, Professor, School of Nursing,
The Hong Kong Polytechnic University, Hong Kong. Telephone: 852
2766 6386.
E-mail: hsaloke@inet.polyu.edu.hk

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 31653171
doi: 10.1111/j.1365-2702.2008.02777.x

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FWM Olivia et al.

disciplines including: computing industries, telecommunication, pharmaceutical industry, electronics and manufacturing
business.
When disaster strikes, the demand for nursing staff is much
greater than that for other healthcare professionals (Lavin
2006). Preparing nurses to respond and handle healthcare
issues before, during and after disastrous situations, including
the recovery stages of society, are crucial in reducing loss of life
or further health problems. As nurses play an important role in
the response to disastrous events, they should be well prepared
by means of education, training and awareness programmes.
Education campaigns can then be further extended to the
public through health talks and promotion by nurses.
Nurses work in different areas, ranging from home care to
hospitals, residential care settings, schools and other communities services. Given the increasing awareness of the need
for good disaster management and the considerable demand
for nursing support during disasters, the role of nurses has
been expanded from primarily the care of the sick and
injured, stationed in hospitals and other healthcare settings,
to the ability to react to a disaster in terms of preparedness,
mitigation, response, recovery and evaluation (Gebbie &
Qureshi 2002). With the expansion of this nursing role, preparing nurses adequately through education may be regarded
as the essential first step in developing disaster nursing.
In view of different understanding and perception of disaster, the working definition for disaster used in this study is:
misfortunate events, happening suddenly and to a collective
unit of people who require outside assistance as the demand of
resources exceeded the ability of the community to cope. It
results in people injury (above 100) or death (more than 10) and
may involve tremendous loss financially, leading to the declaration of a state of emergency (Cox 2004, EM-DAT 2007).
Although awareness of disaster has been increasing among
health professionals, the concept is relatively new to many
nurses in the Hong Kong community, since Hong Kong is
regarded as a lucky place and seldom encounters major
disaster. The recent earthquake (measured at 8083 magnitude) in Sichuan China on 12 May, 2008 undoubtedly has
aroused great concerns among health professionals and
related organisations in Hong Kong on disaster preparedness
and after-care services. Many organisations and professionals
have come to realise the need for guidelines, hygienic food/
water processing, prevention and control of potential infectious diseases and postdisaster management. With the
geographic closeness to China, nurses in Hong Kong should
be aware of the possibility of unforeseeable disasters and be
ready to take part in disaster management.
There is limited research and understanding among nurses
in relation to disaster in Hong Kong. Before establishing the
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specialty of disaster nursing to better prepare nurses in Hong


Kong, exploring nurses perception of disaster is an important
first step for education and the preparation of study
resources. This study aims to identify Hong Kong nurses
perception of disaster and to explore what disaster means to
them. It will thus yield necessary understanding as an initial
step in preparing for the development of a disaster nursing
specialty in Hong Kong.

Origin of the term disaster and related meanings


In astrology, the word disaster has the implication of a bad
event happening or the stars being in a bad position. In fact,
the root of the word disastro comes from Italian, meaning
ill-starred, with dis- meaning away or without and astro
meaning star or planet. The word disaster carries the
meaning of an evil influence of the star or planet (Online
Etymology Dictionary 2001).
The synonyms given for disaster are: tragedy, ruin, debacle,
misfortune, blow, adversity, calamity, catastrophe and cataclysm. Cataclysm refers to adverse happenings often occurring suddenly and unexpectedly, leading to personal or public
upheaval of unparalleled violence. It has an emphasis on the
grief and sorrow caused, while catastrophe refers in particular to the tragic outcome of personal or public destruction
or loss. The general understanding of the term disaster,
refers to an occurrence causing widespread destruction and
distress, a catastrophe or a grave misfortune (American
Heritage Dictionary 2006) the emphasis of which apparently
is on the gravity and scope of the situation.
The meaning and definitions of disasters are broad and
varied. Coming to a common understanding is important to
enable professionals to know what they are referring to. The
World Health Organization (2004) defines disaster as a
sudden ecological phenomenon of sufficient magnitude to
requires external assistance which places more of an
emphasis on natural disasters. It also highlights the abruptness of the occurrence of disasters. Natural disasters include
droughts, epidemics, extreme temperatures, earthquakes,
floods, tsunamis, hurricanes, volcanic eruptions, ice storms,
wind storms, landslides, wild fires and so on.
A disaster can also be man-made and both accidental or
deliberate. According to the International Disaster Database
(EM-DAT), man-made disasters are regarded as technological disasters that are because of industrial, transportation
and other miscellaneous technological causes. Man-made
disasters may include complex emergencies, technological
disasters, such as transport or industrial accidents, material
shortage, contamination of food and water or terrorist
attack.

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Besides looking at the causes of disasters, others have


focused on the aspects of the damages and impact to define a
disaster. NeSmith (2006) defines disaster as an event that is
outside human control. Disasters are also regarded as
unpredictable and unknown, bringing death, injury, destruction and disruption of life to society (Sharma 1972). People
suffer and day-to-day patterns of life are disrupted, resulting
in the need for food, clothing, shelter, medical and nursing
care or other necessities of life. Langan (2005) recognises that
neighboring communities may need to offer assistance in a
disaster situation.

Nurses perception of disaster


When disasters occur, nurses active role in caring for the
victims and those affected is crucial. Nurses effectiveness in
responding to and handling disastrous happenings in relation
to on-site triage, emergency care for the victims, supporting
and protecting others from health hazards; rests on how they
perceive disaster and its nature. Jennings-Sanders et al.
(2005) state that all nurses in all specialties should be
prepared to care for people affected by disasters. The
development of subjects and curricula in disaster nursing
has been urged for all nursing education curriculum (BjornOve & Hengo 1997, Veenema 2006). Providing nurses in
Hong Kong with the necessary knowledge, skills and ability
to respond to a variety of threats promptly during disastrous
situations in accordance with international standards is
essential.
Research on disaster nursing is scanty and there is a
tremendous lack of understanding of nurses perception,
preparedness and education needs with regard to disaster.
More information in these areas is extremely important if a
community is to be prepared for disaster. A survey of nurses
preparedness for disaster has been reported (Fung et al.
2008), while this study reports on Hong Kong nurses
perception of disaster. Nurses perception on disaster, relates
to their awareness of vulnerability to unpredictable disaster;
and affects how prepared nurses should be for disaster. The
understanding of nurses perception on disaster and their
preparedness for disaster will provide culturally and socially
sensitive information and a direction for nursing education
and research development in disaster nursing in Hong Kong.

The study
Aim
The aim of the study was to explore the perception of disaster
among nurses in Hong Kong. The specific study objectives

Nurses perception of disaster

were: (i) to explore nurses description of a disaster; (ii) to


examine which of the tragedies that have occurred in Hong
Kong are considered as disasters by nurses and (iii) to identify
the types of disastrous events that nurses consider likely in
Hong Kong.

Study design
This was a descriptive study. A questionnaire was used to
explore nurses perception of disaster. A convenience sample
of registered nurses with clinical experience in different
settings was recruited from a university in Hong Kong from
AprilJune, 2007.

Participants
The questionnaire was distributed to all registered nurses
studying on a masters degree programme at a university in
Hong Kong. The questionnaire was distributed by the
researcher, who was not involved in the teaching of these
nursing students and collected immediately after completion.
All of these students were registered nurses working in
different hospitals all over Hong Kong. All had received their
basic nursing education in Hong Kong and none had worked
outside Hong Kong.

Questionnaire
The questionnaire was developed by a team of nurse
academics with expertise in emergency care, intensive care
and community health. The questionnaire consisted of four
sections. Section one was designed to solicit information
relating to participants demographic data and nursing
experience; in section two, an open-ended question asked
nurses to describe a disaster in their own words. Section 3
listed some of the tragedies that have occurred in Hong
Kong and asked nurses to indicate which they considered
as disasters. The last section contained a list of types
of disastrous events and asked nurses to the rate the
likelihood of these events occurring in Hong Kong
using a three-point Likert scale (not possible, unlikely or
likely).
A panel of experienced nurses with expertise in emergency
care (two), intensive care (two), community health (one)
and nurse education (two) who have public health and
community health backgrounds, was invited to validate the
questionnaire. Only six questions needed amendment and
minor changes were made for the final version of the
questionnaire. The content validity index was calculated to
be 094, suggesting a high level of validity.

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Ethical considerations
Before the commencement of the study, ethical approval was
obtained from the university where it was conducted.
Permission was granted by the subject lecturers of each class
to access their students. The registered nurse students were
given an explanation of the aim of the study and were assured
that their participation was voluntary and that no penalty
would be incurred for not participating. The questionnaire
was completed anonymously. Return of completed questionnaire is considered as implied consent to the study.

Data analysis
Data were entered using the Statistical Package for the Social
Sciences version 14. Descriptive statistics were used to
examine the demographics of the participants, events considered as disasters by nurses and the likelihood of certain
types of events happening in Hong Kong. Content analysis
was used to analyse the data generated from the open-ended
question state in your own words what is a disaster to you?

Results
Demographics
A total of 164 of the 176 distributed questionnaires were
collected from the classes (response rate 943%). Table 1
shows the demographics of the participants. The majority
were female (817%), aged 2635 (707%) and single
(677%). While two-thirds of them (66%) had more than
five years of clinical experience in nursing, most were bedside
nurses (915%) and only a small number were in managerial
positions (n = 12, 73%). Nearly half worked in medical and
surgical units (433%) and about one-fifth worked in acute
care and specialty units (Table 1).

Nurses perception of disaster


Only 123 out of the total of 164 (75%) answered the openended question state in your own words what is a disaster.
Content analysis was carried out by two of the researchers
separately to analyse the data generated from the open-ended
question that asked the nurses to state what a disaster is in
their own words. Each of the researchers separately identified
the keywords, summarised and then categorised them
according to the responses from the participants and together
discussed and compromised on the categories and keywords
if there was any discrepancy. The descriptions of disaster by
the nurses can be classified into four categories: the charac-

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Table 1 Demographic characteristics of registered nurses in the study


(N = 164)
Demographic characteristics
Gender
Female
Male
Age groups (years)
1825
2635
36 or above
Missing data
Marital status
Single
Married
Years of experience in nursing
<1
15
610
1115
>15
Current position
Registered nurse
Advanced practice nurse/Nurse
specialist/Nursing officer
Enrolled nurse (practicing
registered nurse)
Clinical areas
Med/Surg (Outpatient Dept, Infection
Control Unit, etc.)
Acute Care (Emergency, Intensive Care Unit,
High Dependency Unit, Operating Theatre,
Coronary Care Unit, etc.)
Specialty (Obstetric Unit, Gynaecology,
Neurology, Oncology, Psychiatric, etc.)
Public Health/community health
Others (in-service unit)

n (%)

134 (817)
30 (183)
8
116
38
2

(49)
(707)
(231)
(13)

111 (677)
53 (323)
3
56
54
19
32

(18)
(342)
(329)
(116)
(195)

150 (915)
13 (79)
1 (06)

68 (415)
36 (219)

30 (183)
6 (37)
24 (146)

teristics, the demand for emergency services or care, the


impacts and the events, as examples to illustrate their
understanding of disaster (Table 2).
The respondents described the characteristics of disaster
mostly as unpredictable/sudden/unexpected/unpreventable
(211%), out of control/cannot manage/do not know how
to manage (81%). Other descriptions of characteristics
included urgent/quick response/emergency, horrible happenings/traumatic/crisis/danger and unknown disease with
no treatment available for the time being. Some respondents
described demanding emergency services/care as their
understanding of a disaster. Emergency/immediate medical
attention needed was cited by 154% of the respondents,
challenge to professional services by 81% and requiring
extensive manpower to cope by another 81% of the
respondents. The third most commonly used description

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Nurses perception of disaster

Table 2 Description of disaster by nurses (N = 123)


Themes of disaster descriptions
1 The characteristics
Unpredictable/sudden/unexpected/unprepared
/cannot think of in advance/unpreventable
Out of control/cannot manage/do not know
how to manage/catastrophic/disorganised
Urgent/quick response/emergency
Horrible happenings/traumatic/crisis/danger
Unknown disease with no treatment
available for the time being
2 Demand of emergency service/care
Emergency/immediate medical attention needed
Challenge to services (aspects of care, police, other
professionals/admission to hospital/exceed the
normal service requirements
Required extensive manpower to cope
3 The impacts
Involve large number of victims: injury
or death/fatal/life threatening
Damage to environment/buildings/
destruction/loss of property
Adverse psychological effects/worry/
sadness/tragedy/stress/inability to cope
Loss of family members/significant others
Serious consequences
4 Types of events used to illustrate
their understanding of a disaster
Infectious disease (endemic/pandemic)
Serious accidents/extensive traffic accidents
Terrorist attacks (like 911)
Natural disaster/extreme weather change
War
SARS/avian flu
Airplane crash
Bombing (burn patients)/explosions
Earthquakes
Major fires
World Trade Organization (WTO) demonstrations
Food poisoning (food additives)
Other man-made unfortunate events

n (%)

28 (211)
10 (81)
10 (81)
8 (65)
2 (16)

19 (154)
10 (81)

10 (81)

Unfortunate Hong Kong events that nurses considered as


disasters
A list of unfortunate events that had occurred in Hong Kong
was then provided and the respondents were asked to
indicate whether they considered these events to be disasters
by answering yes or no. The Lan Kwai Fong tragedy
(a district in Hong Kong with a lot of bars, where many
young people go to celebrate during festivals), caused by
overcrowding and a stampede on New Years Eve of 1992
that killed 20 and injured 71, topped the list of disasters
(909%), followed by the SARS pandemic outbreak in 2003
(896%) and the Fire in the Garley Building (a tall building in
a busy district in Hong Kong) (854%). Table 3 shows the
unfortunate events listed according to the proportion of
respondents considering them as disasters.

75 (610)
12 (98)
8 (65)
2 (16)
2 (16)

29
12
4
4
4
3
2
2
2
2
1
1
1

(236)
(98)
(33)
(33)
(33)
(24)
(16)
(16)
(16)
(16)
(08)
(08)
(08)

The likelihood of certain unfortunate events happening


in Hong Kong
Nurses were given a list of possible types of unfortunate
events that can happen around the world and were asked to
indicate the likelihood of these events occurring in Hong
Table 3 Unfortunate events in Hong Kong considered as disasters by
nurses (N = 164)
Rank Unfortunate event
1
2
3
4
5
6

was the impact of a disaster. The involvement of large


numbers of victims (injured or dead) topped the list (610%),
followed by damage to the environment/buildings/destruction/loss of property (98%), adverse psychological effects
(65%), loss of family members/significant others (16%)
and serious consequences (16%). A small number of nurses
also used examples of unfortunate events to explain their
understanding of disaster, such as infectious diseases
endemic or pandemic (236%), serious accidents/extensive
traffic accidents (98%). Other examples included terrorist
attacks, natural disasters, extreme weather changes, war
and SARS, which were cited by a smaller number of
respondents.

7
8
9
10
11
12

13

Lan Kwai Fong tragedy (20 deaths and 71


injuries resulting from a stampede) 1992
Severe acute respiratory syndrome outbreak
(296 deaths, 1755 infected) in 2003
Fire in the Garley building (death toll: 41,
injuries: 80) in 1996
China Airline crash (3 deaths, 209 injuries)
in 1999
Embankment collapse on Sau Mau Ping
(71 killed) in 1972
Building demolished in landslide (67 killed)
in 1972
Landslides in Baguio Villas (2 deaths,
1500 evacuated) 1992
Explosion caused by oil leak from transformer
in West-Rail KCRC (12 injuries) in 2007
Far East Jet-foil wreck (1 death, 119 injuries)
in 1998
Petrol-bomb in Top Once Karaoke (killed 17)
in 1998
Avian flu (infected 18, killed 6) in 1997
Ministerial conference of the World Trade
Organization (5000 protesters, over
1000 arrested, 9 injured) 2005
Poisoning and food additives (frequently reported)
imported from China

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 31653171

n (%)
149 (909)
147 (896)
140 (854)
114 (695)
103 (628)
102 (622)
88 (537)
78 (476)
75 (457)
73 (445)
70 (427)
36 (220)

18 (110)

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FWM Olivia et al.


Table 4 Likelihood of unfortunate events occurring in Hong Kong
Likelihood of happening (N = 164)

Type of unfortunate event

Not possible Unlikely


n (%)
n (%)

Major fire incidents


0
Infectious disease outbreaks
1 (06)
Tragedies resulting from
0
over-crowdedness stampede
Extensive landslides
2 (12)
2 (12)
Major transport accidents
(including aircraft, railways,
ferry incidents)
Chemical spills
3 (18)
General strike/demonstrations
1 (06)
Extreme weather
6 (37)
Severe flooding
11 (67)
Terrorist attacks
8 (49)
Nuclear incidents/radioactive
19 (116)
substances leakage
Earthquakes
29 (177)

Likely
n (%)

9 (55) 101 (616)


8 (49) 100 (610)
58 (354) 80 (488)
38 (232)
10 (61)

78 (476)
75 (457)

45
71
61
42
65
52

74
66
52
48
31
29

(274)
(433)
(372)
(256)
(396)
(317)

26 (159)

(451)
(402)
(317)
(293)
(189)
(177)

8 (49)

Kong. The list included the incidents that had happened in


Hong Kong and the top ten natural and technological
disasters affecting China in the past ten years (EM-DAT).
The top three unfortunate events that were considered most
likely to happen in Hong Kong were major fires (616%),
infectious disease outbreaks (61%) and stampedes resulting
from overcrowding (488%). The disastrous events most
unlikely to happen in Hong Kong were terrorist attacks
(189%), nuclear incidents/leakage of radioactive substances
(177%) and earthquakes (49%) (Table 4).

Discussion
This study first explores nurses description of disaster, which
tragedies that have occurred in Hong Kong are considered by
nurses as disasters and the types of disastrous events that they
consider likely in Hong Kong. While nurses in Hong Kong
considered large numbers of victims as a key characteristic of
a disaster (610%), they did not choose the unfortunate event
in Hong Kong with the largest numbers of deaths as the most
disastrous incidents (Table 3). Instead of the SARS outbreak
with 296 deaths (896%), more of them chose the Lan Kwai
Fong tragedy (909%), which happened on New Years Eve
when people were enjoying themselves. Perhaps the social
astonishment and the sadness associated with tragedy occurring when people were partying had significantly affected
whether nurses saw this as a disaster. Stampede caused by
overcrowding was also cited by 488% of the respondents,
making it the third most likely catastrophic event to occur in
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Hong Kong according to our respondents. In a densely


populated city like Hong Kong, with a population of close to
seven million people dwelling in an area of 1095 km2,
incidents like this involving large numbers of people are not
unimaginable.
Before the SARS outbreak, infectious diseases were seldom
described as disasters. However, the results of this study
showed that it is considered as such by the majority of nurses
(896%), rated as likely to happen by 616% of them and
cited as a description of disaster (236%). Because SARS is a
more recent unfortunate event in Hong Kong, 64% of the
respondents would have been working as registered nurses
and the rest were student nurses at the time of the SARS
outbreak in 2003. The vivid memory could have affected
their perception of this disaster.
Nurses in this study also considered serious accidents and
extensive traffic accidents (98%) and damage to buildings
caused by major fire (98%), to be disasters. This again is due
to the situation of overcrowding in Hong Kong, a city with
busy roads and many tall buildings. The fire in the Garley
building was the third incident considered to be a disaster in
Hong Kong (854%) and topped the list of types of disaster
most likely to happen in Hong Kong (616%). Natural
disasters such as earthquakes or severe flooding and manmade disasters such as nuclear incidents or terrorist attacks
are considered by nurses as unlikely to happen in Hong Kong.
Hong Kong is fortunate that almost no severe disasters have
been reported.

Study limitations
This was a simple survey using a self-completed questionnaire
and a small-scale study involving only nurses studying at a
university and could not be considered representative of the
nursing population. The study could be repeated in other
healthcare settings to recruit bigger and more representative
samples, so that a broader range of opinions can be obtained.

Conclusion and implications for nursing


Disaster is sudden, fast, destructive and mostly unanticipated.
Even though Hong Kong seldom experiences disasters such as
earthquakes or tsunamis like nearby Asian countries, Hong
Kong is by no means immune from disaster. Given our
geographical proximity to the Chinese mainland, nurses need
to be prepared and be aware of the types and likelihood of
unfortunate events and our vulnerability to unpredictable
disaster. In the past few years, the Chinese mainland has
experienced severe flooding and unpredictable wind storms.
Just recently, a blizzard in JanuaryFebruary 2008 and the

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Sichuan earthquake in May 2008 have caught the entire


country by surprise. The Hong Kong Red Cross dispatched a
team to offer help to people in the affected areas. Besides, the
Hong Kong nurses are very supportive and many have
volunteered to take part in the rescue and rebuild events, to
assist in emergency responses for humanitarian reasons.

Relevance to clinical practice


Hong Kong, on its own, also has a high demand for the
development of aircrafts, railways and transport systems,
which puts Hong Kong at risk of disasters related to
overloaded transportation systems. For the healthcare profession, there is a need to be able to prioritise possible
disastrous events and develop appropriate preparedness and
planning for handling different situations. This is part of the
role of disaster nursing. During quiet times or in the
predisaster phase, all nurses (and other related professionals)
around the world should take the opportunity to be equipped
with knowledge and skills for disaster care and prepare the
manpower to face sudden and unexpected challenges.

Relevance to nursing education and research


This study provides information and implications for related
research and the development of a disaster nursing curriculum to meet the global demand for disaster preparedness. All
nursing education programmes should include subjects on
disaster preparedness and management in the curriculum.
Disaster nursing should be also specialty programme for
nurses at postgraduate level. Further research into the general
publics preparedness for disaster, especially among vulnerable population groups, is needed to give a direction for
prioritising the disaster nursing education curriculum.

Contributions
Study design: OF, CL, AYL; data collection and analysis: OF,
AYL and manuscript preparation: OF, CL, AYL.

Nurses perception of disaster

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